应用最佳顺应性设定呼气末正压的临床研究
응용최가순응성설정호기말정압적림상연구
Clinical research of using optimal compliance to determine positive end-expiratory pressure
  • 万方数据
    中国危重病急救医学 중국위중병급구의학
    CHINESE CRITICAL CARE MEDICINE
    2012年 7期 393-397 ,共5页

    徐磊%冯全胜%廉富%邵新华%李智伯%王志勇%李军

    서뢰%풍전성%렴부%소신화%리지백%왕지용%리군

    最佳呼气末正压%准静态压力-容积曲线%顺应性%滴定法 最佳呼氣末正壓%準靜態壓力-容積麯線%順應性%滴定法
    최가호기말정압%준정태압력-용적곡선%순응성%적정법
    Optimal positive end-expiratory pressure%Quasi-static pressure-volume curve%Compliance%Titration
    目的 以低流速法描记准静态压力-容积曲线(P-V曲线)选择最佳呼气末正压(PEEP)作为对照,观察滴定最佳顺应性方法选择最佳PEEP的临床实用性和安全性.方法 选取本院重症监护病房(ICU)2009年11月至2010年12月14例接受机械通气的急性呼吸窘迫综合征(ARDS)患者,分为两组,每组7例;分别使用低流速法描记准静态P-V曲线和滴定最佳顺应性的方法确定最佳PEEP,连续测量3次,比较各组所确定的最佳PEEP值和重复试验的一致性;观察试验前及试验后2、4、6h血流动力学参数、氧合指数(0I)、肺顺应性(C)以及血浆中细胞因子和肺表面活性蛋白D(SP-D)的变化.结果 ①两组性别、年龄、疾病严重程度等基础状态无明显差异.②准静态P-V曲线和滴定最佳顺应性方法确定的最佳PEEP值(cmH20,1 cm H2O=0.098 kPa)无明显差异(11.53±2.07比10.57±0.87,P＞0.05).但准静态P-V曲线描记的重复性差,3次描记的P-V曲线斜率呈逐渐下降趋势,每次确定的最佳PEEP值呈逐渐升高趋势,第3次与第1次描记比较差异有统计学意义(12.80±1.92比10.00±1.58,P＜0.05);而滴定最佳顺应性的方法重复性好,每次确定的最佳PEEP值无明显差异.③描记准静态P-V曲线后患者的心率(HR,次/min)、体温(℃)、白细胞介素-6(IL-6,ng/L)、肿瘤坏死因子-α(TNF-α,ng/L)、SP-D(μg/L)均呈逐渐升高趋势,平均动脉压(MAP,mm Hg,1 mm Hg=0.133 kPa)、连续心排血指数(CCI,L·min-1·m-2)、OI(mm Hg)及C(ml/cm H20)均呈下降趋势,均于试验后6h达峰值或谷值,与试验前比较差异有统计学意义(HR:117.34±8.53比93.71±5.38,体温:38.05±0.73比36.99±1.02,IL-6:144.84±23.89比94.73±5.91,TNF-α:151.46±46.00比89.86±13.13,SP-D:33.65±8.66比16.63±5.61,MAP:85.47±9.24比102.43±8.38,CCI:3.00±0.48比3.81±0.81,OI:62.00±21.45比103.40±37.27,C:32.10±2.92比49.57±7.18,均P＜0.05),提示准静态P-V曲线的描记会加重原有肺损伤;而滴定最佳顺应性试验前后患者HR、MAP、体温、CCI、OI、C、细胞因子及SP-D均无明显差异.结论 滴定最佳顺应性方法确定最佳PEEP重复性好,临床操作更简单、更安全,便于临床开展.
    목적 이저류속법묘기준정태압력-용적곡선(P-V곡선)선택최가호기말정압(PEEP)작위대조,관찰적정최가순응성방법선택최가PEEP적림상실용성화안전성.방법 선취본원중증감호병방(ICU)2009년11월지2010년12월14례접수궤계통기적급성호흡군박종합정(ARDS)환자,분위량조,매조7례;분별사용저류속법묘기준정태P-V곡선화적정최가순응성적방법학정최가PEEP,련속측량3차,비교각조소학정적최가PEEP치화중복시험적일치성;관찰시험전급시험후2、4、6h혈류동역학삼수、양합지수(0I)、폐순응성(C)이급혈장중세포인자화폐표면활성단백D(SP-D)적변화.결과 ①량조성별、년령、질병엄중정도등기출상태무명현차이.②준정태P-V곡선화적정최가순응성방법학정적최가PEEP치(cmH20,1 cm H2O=0.098 kPa)무명현차이(11.53±2.07비10.57±0.87,P＞0.05).단준정태P-V곡선묘기적중복성차,3차묘기적P-V곡선사솔정축점하강추세,매차학정적최가PEEP치정축점승고추세,제3차여제1차묘기비교차이유통계학의의(12.80±1.92비10.00±1.58,P＜0.05);이적정최가순응성적방법중복성호,매차학정적최가PEEP치무명현차이.③묘기준정태P-V곡선후환자적심솔(HR,차/min)、체온(℃)、백세포개소-6(IL-6,ng/L)、종류배사인자-α(TNF-α,ng/L)、SP-D(μg/L)균정축점승고추세,평균동맥압(MAP,mm Hg,1 mm Hg=0.133 kPa)、련속심배혈지수(CCI,L·min-1·m-2)、OI(mm Hg)급C(ml/cm H20)균정하강추세,균우시험후6h체봉치혹곡치,여시험전비교차이유통계학의의(HR:117.34±8.53비93.71±5.38,체온:38.05±0.73비36.99±1.02,IL-6:144.84±23.89비94.73±5.91,TNF-α:151.46±46.00비89.86±13.13,SP-D:33.65±8.66비16.63±5.61,MAP:85.47±9.24비102.43±8.38,CCI:3.00±0.48비3.81±0.81,OI:62.00±21.45비103.40±37.27,C:32.10±2.92비49.57±7.18,균P＜0.05),제시준정태P-V곡선적묘기회가중원유폐손상;이적정최가순응성시험전후환자HR、MAP、체온、CCI、OI、C、세포인자급SP-D균무명현차이.결론 적정최가순응성방법학정최가PEEP중복성호,림상조작경간단、경안전,편우림상개전.
    Objective To observe the availability and security of optimal compliance strategy to titrate the optimal positive end-expiratory pressure (PEEP),compared with quasi-static pressure-volume curve (P-V curve) traced by low-flow method.Methods Fourteen patients received mechanical ventilation with acute respiratory distress syndrome (ARDS) admitted in intensive care unit (ICU) of Tianjin Third Central Hospital from November 2009 to December 2010 were divided into two groups (n=7).The quasi-static P-V curve method and the optimal compliance titration were used to set the optimal PEEP respectively,repeated 3 times in a row.The optimal PEEP and the consistency of repeated experiments were compared between groups.The homodynamic parameters,oxygenation index ( OI ),lung compliance (C),cytokines and pulmonary surfactant-associated protein D (SP-D) concentration in plasma before and 2,4,and 6 hours after the experiment were observed in each group.Results ① There were no significant differences in gender,age and severity of disease between two groups.②The optimal PEEP (cm H2,O,1 cm H2O=0.098 kPa) had no significant difference between quasi-static P-V curve method group and the optimal compliance titration group ( 11.53 ± 2.07 vs.10.57 ± 0.87,P＞0.05 ).The consistency of repeated experiments in quasi-static P-V curve method group was poor,the slope of the quasi-static P-V curve in repeated experiments showed downward tendency.The optimal PEEP was increasing in each measure.There was significant difference between the first and the third time (10.00 ± 1.58 vs.12.80 ± 1.92,P＜0.05).And the optimal compliance titration method had good reproducibility as the optimal PEEP without significant difference in each measure.③ After the quasi-static P-V curve traced,the heart rate ( HR,bpm),temperature ( ℃ ),interleukin-6 ( IL-6,ng/L),tumor necrosis factor-α (TNF-α,ng/L),SP-D (μg/L) showed a gradually increasing tendency,the mean artery pressure ( MAP,mm Hg,1 mm Hg=0.133 kPa),continuous cardiac index (CCI,L·min-1·m-2),OI (mm Hg),and C (ml/cm H2O) showed a gradually decreased tendency,all of these parameters reached the peak or trough at 6 hours after the experiment,and there was significance compared with those before experiment (HR:1 17.34 ± 8.53 vs.93.71 ± 5.38,temperature:38.05 ± 0.73 vs.36.99 ± 1.02,IL-6:144.84 ± 23.89 vs.94.73 ± 5.91,TNF-α:151.46 ±46.00 vs.89.86 ± 13.13,SP-D:33.65 ±8.66 vs.16.63 ± 5.61,MAP:85.47 ± 9.24 vs.102.43 ± 8.38,CCI:3.00 ± 0.48 vs.3.81 ± 0.81,OI:62.00 ± 21.45 vs.103.40 ± 37.27,C:32.10 ± 2.92 vs.49.57 ± 7.18,all P＜ 0.05 ).The results suggested that the drawing of quasi-static P-V curve would aggravate the lung injury.And in optimal compliance titration method group,there were no significant differences in HR,MAP,temperature,CCI,OI,C,cytokines and SP-D before and after titration.Conclusion Optimal compliance titration method has good reproducibility,safty and usability.
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